IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


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Photographic 

Sciences 
Corporation 


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0' 


Coloured  covers/ 
Couverture  de  couleur 


I    ~y  Covers  damaged/ 


Couverture  endommagee 

□    Cov 
Cou 


n 


□ 


D 


Covers  restored  and/or  laminated/ 
verture  restaurde  et/ou  pellicul^e 


□    Cover  title  missing/ 
Le  titre  de  couverture  manque 

□    Coloured  maps/ 
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Ce  document  est  film6  au  taux  de  reduction  indiqu6  ci-dessous. 

10X  14X  18X  22X 


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The  last  recorded  frame  on  each  microfiche 
shall  contain  the  symbol  — ^  (meaning  "CON- 
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whichever  applies. 


Les  images  suivantes  ont  6t6  reproduites  avec  le 
plus  grand  soin,  compte  tenu  de  la  condition  et 
de  la  nettetd  de  l'exemplaire  filmd,  et  en 
conformity  avec  les  conditions  du  contrat  de 
filmage. 

Les  exemplaires  originaux  dont  l£  couverture  en 
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dernidre  page  qui  comporte  une  empreinte 
d'impression  ou  d'illustration,  soit  par  le  second 
plat,  selon  le  cas.  Tous  les  autres  exemplaires 
originaux  sont  film^s  en  commenpant  par  la 
premidre  page  qui  comporte  une  empreinte 
d'impression  ou  d'illustration  et  en  terminant  par 
la  dernidre  pa^a  qui  comporte  une  telle 
empreinte. 

Un  des  symboles  suivants  apparaitra  sur  la 
dernidre  image  de  cheque  microfiche,  selon  le 
cas:  le  symbo(«  — ♦►  cignifie  "A  SUIVRE  ".  le 
symbole  V  signifib  "FIN". 


Maps,  plates,  charts,  etc.,  may  be  filmed  at 
different  reduction  ratios.  Those  too  large  to  be 
entirely  included  in  one  exposure  are  filmed 
beginning  in  the  upper  left  hand  corner,  left  to 
right  and  top  to  bottom,  as  many  frames  as 
required.  The  following  diagrams  illustrate  the 
method: 


Les  cartes,  planches,  tableaux,  etc.,  peuvent  §tre 
film^s  d  des  taux  de  reduction  diff6rents. 
Lorsque  le  document  est  trop  grand  pour  dtre 
reproduit  en  un  seul  clich6,  il  est  film6  d  partir 
de  Tangle  sup6rieur  gauche,  de  gauche  d  droite, 
et  de  haut  en  bas,  en  prenant  le  nombre 
d'images  n6cessaire.  Les  diagrammes  suivants 
illustrent  la  mdthode. 


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2  Z'y 


SURGERY  AMONG  THE  INSANE  IN  CANADA 


From 


BY 


R.  M.   BUCKE,   M.  D. 
President  of  the  Medico- Psychological  Association 


AMERICAN  JOURNAL  OF  INSANITY 
Vol.  LV,  No.  i,  1898 


^^ 


■Wi 


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n       -.    ^ 


J 


1 


Volume  LV 


JULY,  1898 


No.  I 


AMERICAN 

JOURNAL  OF  INSANITY 


SURGERY  AMONG  THE  INSANE  IN  CANADA/ 


BvR.  M.  BUCKE,  M.  D., 
President  of  the  Medico-Psychc'ogical  Association . 

In  addressing  you  as  I  have  the  honor  to  do  to-day  as  presi- 
dent of  this  old  and  honorable  association,  I  desire  to  avoid 
mere  theory  and  speculation,  to  which,  as  you  well  know,  I 
am  too  much  addicted,  and  speak  on  some  subject  of  practical 
interest.  And  I  shall  endeavor,  as  far  as  in  me  lies,  not  onlv 
to  be  practical,  but  to  present  such  thoughts  and  facts  as  may 
have  a  direct  bearing  and  influence  upon  that  which  we  all  have 
at  heart — the  relief  of  suffering  and  cure  of  disease. 

A.S  to  the  precise  subject  chosen  for  my  address,  I  am  not  sure 
that  I  should  not  ofifer  you  some  apology  for  it,  and  that  for  two 
reasons:  First,  because  I  read  a  very  brief  paper  upon  it  two 
years  ago  in  Boston,  and  secondly,  because  it  does  not  seem,  as 
far  as  I  can  judge,  a  popular  topic.  My  answer  to  the  first  objec- 
tion is  that  my  experience  of  the  subject  has  more  than  trebled  in 
the  last  two  years  and  that  what  I  have  to  say  now  will  be  based 
on  so  much  broader  an  induction  as  to  make  it  greatly  more 
worthy  of  attention.  To  the  second  objection  my  reply  is  that, 
if  to  the  members  of  the  association  the  subject  is  unpalatable 
that  is  all  the  more  reason  for  insisting  upon  the  consideration 
of  it,  since,  to  my  mind  at  least,  it  is  certam  that  either  we  or  our 

^  Presidential  address  before  the  American  Medico-Psychological  Asso- 
ciation at  St.  Louis,  May  10,  1898. 


2  SURGERY   AMONG   THE   INSANE   IN    CANADA  [July 

immediate  successors  will  have  to  deal  with  it  practically;  that 
we  shall  not  be  able  long  to  ignore  it;  and  that  for  the  sake  of 
our  own  good  name,  as  well  as  for  the  sake  of  our  patients,  the 
sooner  we  take  it  up  and  seriously  consider  it  the  better. 

Before  entering  upon  my  own  experience  I  shall  refer  for  a 
few  minutes  to  that  of  three  other  men,  namely,  Dr.  Hall  of 
Victoria,  B.  C,  Dr.  Burgess,  of  the  Protestant  Hospital  for  the 
Insane,  Montreal,  Q.,  and  Dr.  Holmes  of  Chatham,  Ont. 

Dr.  Hall  has  operated  in  two  cases  only;"  he  reports  them  as 
follows:  A.  B.,  married  woman,  aet.  38,  youngest  child  eight 
years  old.  At  time  of  operation  she  had  been  insane  thr<>e  and  a 
half  years.  She  had  been  two  years  and  eight  months  of  that 
time  in  an  asylum  in  Victoria.  She  was  considered  to  be  a  hope- 
less case.  The  right  ovary  was  cystic  and  the  left  prolapsed; 
there  were  tubal  adhesions.  He  removed  tubes  and  ovaries 
7th  Jan.,  i8q8.  Thirteen  day^,  after  operation  she  began  to  im- 
prove, thirty-five  days  after  she  went  home  well.  She  has 
remained  well  since.  She  is  at  present  as  well  as  ever  she  was 
and  manages  her  house  as  before  she  Avas  insane. 

C.  D.,  married  woman,  aet.  61,  several  children,  a  case  of 
delusional  mania,  was  in  an  asylum  eight  months.  On  examina- 
tion he  found  eror.ion  of  cervix,  laceration  of  perineum,  both 
ovaries  cystic.  He  removed  both  ovaries  and  did  what  was 
needed  besides.  The  patient  at  once  improved  and  remained  so. 
So  far,  however,  she  is  not  perfectly  well  mentally. 

Dr.  Burgess  reports  the  following  three  cases: 

L.  M.,  admitted  July,  1890;  hysterical  mania  of  over  a  year's 
standing;  had  frequent  epileptiform  convulsions,  was  violent, 
noisy  and  destructive;  examined  by  Dr.  Gardiner,  who  found 
intense  irritation  of  both  ovaries.  These  were  removed  in 
October,  1891  (patient  had  been  insane  about  two  years  at  that 
time).  She  improved  at  once  and  by  the  middle  of  December 
was  well.  She  was  last  heard  from  October,  1892,  was  then  in 
England ;  was  quite  well. 

E.  H.  B..  admitted  December,  1891,  aet.  34,  married,  three 
children.  A  case  of  suicidal  melancholia  of  fourteen  months' 
standing;   examined    by    Dr.    Gardiner  in   January,    1892.     He 

'  See  "  Canadian  Pract.,"  April,  J898. 


TM» 


1898] 


R.    M.    nUCKE 


found  cndo;Tietritis,  laceration  of  cervix,  and  disease  of  right 
ovary.  She  was  operated  on  in  March,  1892.  Curetted,  cervix 
repaired,  right  ovary  removed.  Recover>-  both  mental  and  phy- 
sical at  once  set  in.  She  was  discharged  recovered  and  at  last 
accounts  was  keeping  well. 

M.  A.  C.  aet.  40,  married,  seven  children.  A  case  of  mania 
of  SIX  months'  standing,  both  suicidal  and  homicidal.  Examined 
in  July,  1894,  a  month  after  her  admission,  by  Dr.  Alloway.  He 
found  retroversion  of  uterus  and  endocervicitis;  patient  operated 
on  same  month  and  diseased  conditions  removed.  Improve- 
ment both  mental  and  physical  set  in  at  once.  She  was  not 
perfectly  well  until  the  end  of  1895,  that  is,  sixteen  months  after 
operation.     She  has  remained  quite  well  since  that  date. 

Dr.  Holmes  is  an  ex-president  of  the  Canadian  Medical  Asso- 
ciation and  one  of  the  best  general  practitioners  that  I  know 
Years  ago  he  came  to  the  conclusion  i  at  puerperal  insanity  is 
nearly  always   dependent   upon   some   lesion  of  the   generative 
organs.     As    early   as    1867    he    (apparentlv)    cured   a   case   of 
puerperal  mama  which  had  resisted  other  treatment  and  threat- 
ened to  become  permanent  by  relieving  surgically  a  lacerated 
cervix  uteri.     I   say   "apparently"    cured    because   the   woman 
recovered   after  having  been   operated   upon  and  tlie   recoverv 
seemed  to  be  due  to  the  operation.     Since  1867  Dr.  Holmes  has 
operated  with  a  similar  result  twenty-three  times,  that  is,  he  has 
had  altogether  twenty-four  recoveries  in  puerperal  insanity  fol- 
lowing  in   every   case   the   removal,    by   operation,   of   ^urgical 
lesions.     Later  I  shall  refer  to  one  of  his  cases  which  seems  to 
be  particularly  instructive  on  the  point  of  the  causation  of  the 
insanity  by  the  lesion. 

I  wish  to  say  further  that  many  of  the  best  men  in  the  pro- 
fession have,  rightly  or  wrongly,  come  to  think  to-dav  that  there 
is  a  much  closer  relation  between  organic  disease  of  the  uterus 
and  Its  adnexa  and  insanity  than  is  generally  recognized  by 
alienists.  I  may  especially  mention  in  this  connection  Robert 
Barnes,  who  in  discussing  before  the  British  Gynecological 
Society  a  case  of  mental  recovery  following  operation  said:  "If 
the  present  case  had  got  into  any  asvlum  I  believe  she  would 
have  remained  there,  for  I  think  it  a  great  fault  in  the  organiza- 
tion of  our  asylums  that  there  is  no  provision  for  the  examina- 


4  SURGERY    AMONG   THE   INSANE   IN    CANADA  U^^Y 

♦  ion  of  such  cases."  And  he  goes  on  to  say :  "  There  is  no  rea- 
son why  a  woman  in  an  asykim  who  is  suffering  from  a  uterine 
complaint  should  not  be  attended  to  whether  or  not  it  makes 
any  difference  in  her  mental  state."  And  More  Madden  gives  it 
as  his  opinion;  "That  many  women  are  needlessly  and  improp- 
erly confined  in  asylums  suffering  from  reflex  cerebro-nervous 
disturbances  consequent  upon  peri-uterine  irritation  or  disease," 
who  might  be  cured  by  operative  or  other  local  treatment.  So 
Skene  in  his  Medical  Gynecology,  writing  from  his  point  of  view, 
tells  us:  "How  sadly  the  condition  of  the  reproductive  system 
has  been  neglected  "  by  asylum  physicians,  and  cites  cases  of 
insanity  in  women  in  which  uterine  disease  co-existed  but  had 
not  been  looked  for  or  suspected  by  the  alienist.  Tliis  author, 
while  teaching  the  probable  frequency  of  utero-ovarian  disease  in 
insane  women  is  needlessly  troubled  about  the  alleged  difficulty 
in  diagnosing  it. 

I  will  add  in  this  connection  that  I  was  rejoiced  to  note  that 
Dr.  Kellogg,  almost  alone  among  the  systematic  writers  on 
insanity,  in  his  recent  exhaustive  treatise,  fully  recognizes  the 
relation  existing  between  utero-ovarian  disease  and  mental  alien- 
ation and  tells  us  that  the  residt  of  gj'necological  treatment  within 
the  past  few  years  fully  confirms  the  theory  that  pelvic  disease 
in  women  may  be  and  at  times  is  a  cause  of  insanity;  and  that 
the  removal  of  the  pelvic  disease  by  operation  is  often  followed 
by  relief  or  cure  of  the  mental  alienation.  In  this  declaration  of 
Dr.  Kellogg's  I  discern,  or  think  I  do,  the  dawn  of  a  better  day 
in  the  writing  of  text-books  on  insanity. 

But  the  point  I  wish  to  accentuate  is  that  many  leading  prac- 
titioners and  gynecologists  either  strongly  suspect  or  think  they 
know  that  there  exists  in  insane  women  a  great  deal  of  unrecog- 
nized and  therefore  neglected  pelvic  disease  and  that  that  disease 
has  more  or  less  to  do  with  the  causation  of  the  insanity  in  many 
if  not  all  of  these  cases.  And  they  further  think  that  from  the 
point  of  view  of  both  physical  and  mental  health  these  utero- 
ovarian  diseases  ought  to  be  diagnosed  and  where  possible 
removed. 

But  it  is,  I  think,  a  still  more  important  fact  that  not  only  do 
many  of  the  leading  members  of  the  profession  think  thus  and 
strongly  condemn  those  alienists  who  do  not  give  their  patients 


1898J  R.    M.    BUCKE  5 

this  chance  of  recovery.  I  say  it  is  a  still  more  important  fact 
that  the  same  opinions  are  hecominj:^  common,  not  to  say  uni- 
versal, in  the  profession  at  larp^e.  and  it  looks  as  if  those  of  us 
who  will  not  move  in  this  matter  may  expect  ver\'  shortly  to  be 
condemned  by  the  profession  of  which  we  are  members,  and  to 
which  we  stand  in  one  special  and  important  department  of  prac- 
tice as  consultants.  These  are  strong  words  and  should  not  be 
used  unless  they  are  true,  and  I  will  lose  no  time  in  explaining 
to  you  why  I  believe  that  they  are  so  and  why  I  have  thought 
it  my  duty  to  use  them  in  this  place. 

Over  three  years  ago  we  began  at  London  Asylum  the  special 
work  about  which  I  am  to  speak  to  you  to-day.    We  had  no  in- 
firmary, and  in  order  to  do  the  work  at  all  we  had  to  fit  up  a  couple 
of  rooms  on  a  fourth  floor.     We  had  not  there  sufificient  space 
for  our  n-ork  and  having  no  elevator  the  constant  use  of  these 
rooms  so  high  up  involved  much  labor.     As  soon  as  I  became 
satisfied  that  the  work  was  going  to  be  successful  and  would  go 
on  I  began  asking  the  Government  for  an  infirmary.     It  was  not 
granted,  largely  because  the  Government  was  advised  by  certain 
doctors  that  the  work  was  unnecessary  and  in  fact  undesirable. 
I  was  questioned  by  the  Government  on  this  point.     It  was  said 
to  me  that  the  profej^sion  at  large  would  not  endorse  this  work, 
and  it  was  intimated  that  the  Government  could  not  promote  a 
work  of  so  serious  a  nature  unless  the  general  sense  of  the  pro- 
fession was  behind  it.     In  order  to  find  out  what  the  profession 
of  my  district  of  western  Ontario  thought  on  the  point  (for  they 
are  the  men  to  whom  I  stand  in  the  relation  of  a  consultant,  and  it 
is  they  who  constitute,  as  far  as  I  am  concerned,  the  court  of 
final  appeal)— in  order  then  to  find  out  their  opinion  and  wishes 
in  the  premises,  I  issued  to  them  a  circular-letter  dated  i6th  of 
November  last.     In  it  I  stated  what  we  at  the  asylum  had  done 
and  were  doing  and  asked  each  man  individually  to  give  me  his 
frank  opinion  of  the  work,  whether  it  ought  to  go   on,   and 
whether  or  not  it  was  the  duty  of  the  Government  to  encourage 
the  work  by  providing  suitable  buildings,  instruments  and  appli- 
ances for  doing  it? 

There  are  in  my  .isylum  district  some  three  hundred  and  fifty 
practitioners.  They  were  all  asked  the  above  questions.  From 
them  I  had  tv;o  hundred  and  fifty-five  answers  which  remain  on 


6  SURGERY   AMONG   THE   INSANE    IN   CANADA  [July 

file  at  London  Asylum  and  which  I  should  be  happy  to  show  any 
one  who  would  like  to  examine  them.  I  have  made  it  my  busi- 
ness to  carefully  read  and  analyze  these  answers,  as  upon  them 
was  basf'd  a  deputation  to  the  Govermnent  on  the  fifteenth  of 
December  urging  upon  them  that  they  should  build  the  infirm.-try 
in  question  and  otherwise  support  and  encourage  the  work.  Ilie 
answers  received  to  my  circular-letter  surprised  me  and  will  per- 
haps surprise  you.     They  were  in  brief  as  follows: 

2  Opposed  the  work, 

3  Were  non-committal, 

ID  Expressed  moderate  approval, 
35  Expressed  strong  approval,  while 
205  Expressed  very  strong  approval  and  said  it  was  the  duty 
of  the  asylum  stafif  to  carr)-  on  the  work. 

I  will  read  a  few  extracts  from  these  letters  to  show  the  tone 
of  them: 

1.  "  I  consider  that  this  work  should  be  done  in  every  case  and 
that  it  is  your  duty  to  see  that  it  is  done." 

2.  "  The  work  should  certainly  be  done." 

3.  "  The  work  ought  to  be  done." 

4.  "  There  is  not  a  shadow  of  doubt  that  in  all  the  cases  oper- 
ated upon,  the  mental  and  physical  condition  of  the  patients  were 
aggravated  by  disease  which  could  only  be  remedied  by  opera- 
tions similar  to  those  performed." 

5.  "  Many  cases  of  insanity  in  females  arise  from  uterine  dis- 
eases; operation  should  in  all  cases  be  done." 

6.  "  I  unhesitatingly  say  that  this  work  should  go  on." 

7.  "  Having  been  present  at  many  of  the  gynecological  opera- 
tions at  your  asylum  during  the  years  '96  and  '97,  I  am  sure  that 
the  operations  performed  in  each  case  were  necessary  for  the 
physical  welfare  of  the  patient." 

8.  "  I  am  in  favor  of  the  work  done  at  your  institution.  I  have 
witnessed  some  of  the  work  and  can  state  positively  that  in  the 
cases  where  I  was  present  the  disease  justified  the  operation." 

9.  "  This  work  should  receive  the  consideration,  the  respect, 
the  encouragement  and  the  hearty  co-operation  of  all." 

10.  "  I  think  it  is  the  duty  of  asylum  authorities  to  examine 
patients  to  find  out  if  there  may  be  some  local  cause  of  the  in- 
sanity.    I  coi.-ider  you  have  done  good  work  and  should  be 


iifc^. 


1898J  R.    M.    DUCKE  7 

encouraged  in  it.     I  would  he  quite  satis  ied  to  accept  the    'ork 
done  at  your  asylum  01  behalf  of  any  patient  I  might  send." 

11.  "The  Government  should  provide  proper  facilities  for  the 
work,  especially  in  the  matter  of  'niproved  hospital  accom- 
modation." 

12.  "  I  have  watched  with  considerable  interest  the  work  done 
at  the  London  Asylum,  although  not  takmg  any  particular  in- 
terest in  mental  disease.  Visits  to  various  asylums  have  led  me  to 
the  conclusion  that  there  is  little  fear  of  meddlesome  gynecology 
being  practiced  in  them,  in  most  the  tendency  being  in  an  en- 
tirely opposite  direction,  namely,  not  to  interfere  at  all.  1  trust 
you  will  continue  the  work  and  urge  upon  the  Government  the 
necessity  of  providing  ways  and  means  for  carrying  it  on  in  the 
most  modern  and  scientific  manner." 

It  is  needless  to  pursue  this  branch  of  the  subject.  These 
extracts  give  a  perfectly  fair  representation,  in  petto,  of  the  two 
hundred  and  fifty-five  letters  from  twelve  of  which  they  are  taken. 
Not  picked  out,  but  as  they  came  to  hand.  It  may  be  that 
western  Ontario  is,  in  this  matter,  an  exceptional  district,  though 
I  do  not  see  why  it  should  be  so;  but  if  it  is  not,  the  answers  to 
this  circular  throw  a  flood  of  light  on  the  feeling  of  the  profession 
at  large  on  the  question  of  gynecology  in  the  asylum. 

Now  I  am  not  here  to  say  that  we  should  for  one  moment 
accept  the  dictum  of  the  outside  profession  on  any  matter  relating 
to  our  own  special  work  about  which  we  should  be  and  are  the 
best  and  final  judges.  But  I  do  say  this:  Tliat  if  we  find  a  wide- 
spread, almost  universal  belief  of  this  kind  in  the  mind  of  the 
general  profession,  we  should  not  be  wise  to  conclude  that  it  is 
unfounded  until  we  have  taken  pains  to  satisfy  ourselves  of  the 
truth  or  untruth  of  it.  To  say,  as  I  have  heard  superintendents 
say,  that  there  is  little  or  no  pelvic  disease  among  their  female 
patients,  and  declare  in  the  next  breath  that  they  had  never 
looked  for  such  disease  because  they  did  not  think  it  right  to 
make  the  necessary  examination  without  evidence  in  the  first 
place  of  such  lesion  as  would  justify  it,  is,  I  venture  to  think,  rash. 

I  suppose  it  is  not  impossible  that  there  might  be  in  a  given 
asylum  eighty  or  ninety  per  cent  of  pelvic  disease  in  the  female 
patients  and  a  hundred  miles  away  another  asylum  in  which  the 
female  patients  (drawn  from  an  identical  population)  were  free 


ijf\ 


^—Ti^mm-    "■''f^'"-'"  '^ 


8  SURGERY   AMONG   THE   INSANE   IN    CANADA  [July 

from  that  class  of  maladies.  But  could  you  expect  that  any  one 
would  believe  it  as  long  as  the  investigation  which  revealed  the 
disease  in  the  one  asylum  had  been  totally  unpracticed  in  the 
other? 

I  have  said,  and  shown,  that  there  is  a  feeling  in  the  mind  of 
the  general  profession  that  there  is  a  good  deal  of  pelvic  disease 
among  female  lunatics;  also  that  such  disease  has  often  a 
causative  relation  to  the  mental  alienation  existing;  further,  that 
it  is  the  duty  of  asylum  physicians  to  make  sure  whether  such 
disease  exists  in  any  given  case  and  to  remove  it  if  it  does; 
also,  that  great  benetii  vill  on  the  whole,  result  to  such  female 
patients  from  the  removal  of  such  disease.  If  this  feeling  is  well 
founded  it  is  surely  most  important  that  in  all  asylums  it  should 
be  heeded  and  acted  upon ;  if  ii  is  not  it  is  almost  as  important  to 
asylum  superintendents  to  show  that  it  is  based  on  a  misappre- 
hension of  the  facts. 

I  want  nov^  to  tell  you  something  of  our  experience  on  the 
subject  in  London  Asylum  during  the  last  three  years.  I  cannot 
possibly  go  into  details  of  cases,  many  of  which  have  been  given 
in  a  prior  paper  and  in  my  last  three  annual  reports.  Each  case 
is  of  course  kept  in  a  special  book  at  the  asylum;  this  and  the 
cases  themselves  are  freely  offered  for  ini,pection  by  any  porson 
who  feels  a  scientific  interest  in  the  subject. 

It  must  not  be  supposed  that  I  desire  or  expect  any  particular 
credit  to  be  given  to  me  personally  for  this  work;  if  credit  is  due 
to  any  one  it  is  payable  in  the  first  place  to  Dr.  Hobbs,  my  third 
assistant,  who  operates,  and  in  the  second  to  Dr.  Meek,  a  London 
gynecologist,  who  has  been  from  the  beginning  his  principal 
assistant.  This  being  the  case,  it  cannot  be  claimed  by  any  one 
that  I  am  led  away  by  desire  or  expectation  of  notoriety,  as  none 
could  redound  to  me  under  any  circumstances.  I  am  simply  a 
more  or  less  intelligent,  and,  I  trust,  impartial  spectator,  witness 
and  reporter. 

And  now  to  show  the  frequency  of  pelvic  disease  among 
female  patients,  at  least  in  my  asylum  at  London,  I  must  give 
you  the  results  of  our  examinations  down  to  date.  They  are  as 
follows:  We  have  examined  altogether  132  patients  and  found 
organic  disease  in  122  of  them;  only  ten  patients  of  the  entire 
number  being  free   from   such    disease.     Of  the    122   cases   of 


1898]  R.    M.    BUCKE  9 

organic  disease,  we  have  operated  on  109;  'here  remain  8  others 
to  be  operated  upon,  and  there  were  5  cases  which,  although  the 
subjects  of  organic  disease,  were  not  suitable  cases  for  operation. 

I  do  not,  of  course,  claim  or  suppose  that  these  figures  indicate 
the  percentage  of  organic  pelvic  disease  in  all  insane  women. 
We  have  naturally  examined  those  cases  in  which  there  seemed 
the  greatest  likelihood  of  finding  disease.  But  after  making  all 
allowance  for  that  fact  the  result  of  our  examinations  remains 
sufficiently  startling. 

It  has  been  charged  against  us  that  we  imagine  disease  exists 
and  then  look  for  it  and  (even  if  it  is  not  there)  find  it.  The 
answer  to  this  friendly  suggestion  is  that  we  never  operate  on 
our  own  diagnosis;  this  is  always  either  made  for  us  or  con- 
firmed by  at  least  one  outside,  thoroughly  competent  man,  who 
is  entirely  independent  of  all  members  of  the  asylum  staff.  I 
myself  never  take  part  in  making  the  diagnosis,  but  am  always 
present  at  the  operations  and  am  always  satisfied  by  actual  obser- 
vation that  the  disease  which  I  had  been  told  was  diagnosed  is 
actually  present. 

In  every  operation,  as  well  as  in  every  diagnosis,  we  are 
assisted  by  at  least  one  expert  gynecologist  as  well  as  other  good 
surgeons  who  are  all  entirely  unconnected  with  the  asylum,  and 
the  diagnosis  previously  made  is  verified  by  them  as  well  as  by 
myself.  It  is  simply  impossible  (the  way  our  work  is  done)  that 
we  could  diagnose  and  operate  for  a  diseased  condition  that  did 
not  exist. 

Our  surgical  work  is  divisible  into  two  main  sections: 
I.  Gynecological  work,  and 

II.  Ordinary  surgery. 

In  the  first  division  there  are  109,  and  in  the  second,  32  cases. 

The  109  gynecological  cases  presented  the  following  patho- 
logical conditions,  often  several  in  one  case: 

In  14  cases  there  was  dysmenorrhoea  or  menorrhagia;  in  62 
cases  there  was  disease  of  the  endometrium;  in  63  cases  there  was 
subinvolution  of  the  uterus;  in  25  cases  there  were  hypertrophied 
cervices;  in  34  cases  there  were  lacerated  cervices;  in  19  cases 
there  were  cystic  cervices;  in  3  cases  there  were  polypi  of  the 
cervix;  in  7  cases  there  was  fibroid  tumor  of  uterus;  in  i  case 
there  was  epithelioma  of  uterus;  in  i  case  there  was  sarcoma  of 


10  SURGERY    AMONG    THE    INSANE    IN    CANADA  [July 

Uterus;  in  33  cases  there  was  retroversioti  of  the  uterus;  in  5  cases 
there  was  complete  procidentia  of  the  uterus;  in  18  cases  there 
was  ovarian  tumor,  often  with  disease  of  the  tubei.;  in  22  cases 
there  were  perineal  injuries  with  their  sequential  diseases;  in  i 
case  there  was  recto-vaginal  fistula;  in  i  case  there  was  an  ischio- 
rectal fistula.  A  total  of  309  diseased  conditions  in  the  109 
cases. 

The  operations  performed  (often  several  in  one  case)  were  the 
following: 

Curettage  and  divulsion 83  times. 

Operations  on  cervix 38  " 

Suspension  of  displaced  uteri 26  " 

Ovariotomies  12  " 

Hysterectomies   16  " 

Perineorrhaphies    17  '* 

Laparotomies  for  tubercular  peritonitis 2  " 

Operation  for  hematoma  of  ovarian  ligament.  .    i  " 

Total 195       " 

The  result  of  these  one  hundred  and  ninety-five  operations  per- 
formed on  one  hundred  and  nine  patients  have  been,  so  far,  as 
follows : 

First  as  regards  bodily  health:  In  three  cases  the  patient  died 
as  a  result  of  the  operation.  In  nearly  all  the  rest  of  the  cases 
where  there  has  been  time  enough  for  any  result  to  follow,  the 
physical  health  of  the  patient  has  been  restored  o**  greatly  im- 
proved. 

Then  as  regards  mental  health: 

In  39  cases  the  patient  recovered  from  her  insanity. 

In  32  other  cases  there  has  been  improvement,  often  very 
marked,  in  the  mental  healtn  01  the  patient. 

In  35  cases  there  has  been  no  improvement  in  the  patient's 
mental  condition. 

So  that  seventy-one  out  of  the  one  hundred  and  six  patients 
who  survived  the  operation,  either  recovered  their  mental  health 
or  this  was  improved. 

The  length  of  time  that  the  seventy-one  patients  who  either 
recovered  or  improved  had  been  insane  at  the  time  of  the  opera- 
tion was  as  follows: 


1898]  R.    M.    BUCKE  II 

Under  one  year  21 

Between  one  and  two  years 14 

Between  two  and  three  years 10 

Between  three  and  four  years 5 

Between  four  and  five  years 2 

Between  five  and  ten  years 11 

Over  ten  years 8 

Total 71 

It  is  my  conviction  that  very  few  of  these  patients  would  have 
either  recovered  or  greatly  improved  if  they  had  not  been  oper- 
ated upon;  it  is  quite  certain  that  many  who  did  recover  or  im- 
prove would  have  done  neither  had  their  physical  disease  not 
been  removed.  Some  of  those  who  did  well  must  have  very 
soon  died  had  no  operation  been  done. 

In  order  to  show  clearly  that  at  least  sometimes  the  removal 
of  the  physical  disease  was  the  cause  of  the  mental  recovery  I 
will  cite  a  few  cases,  and  before  giving  any  of  my  own  I  will 
instance  one  already  referred  to  which  was  treated  and  reported 
by  Dr.  Holmes.  The  woman,  named  E.  R.,  had  a  good  family 
history,  had  always  enjoyed  good  health,  was  married  at  the  age 
of  twenty-four  and  remained  in  perfect  health  during  the  first 
two  years  of  her  married  life.  She  then  began  to  suffer  from 
mental  depression,  which  gradually  increasc^d  until  her  husband 
feared  she  might  attempt  to  take  her  life  and  he  provided  her  with 
a  companion  as  a  precaution.  While  in  this  condition  she  became 
pregnant  for  the  first  time.  When  labor  came  on  it  was  found 
that  the  child  could  not  be  delivered  alive  on  account  of  a  large 
hard  tumor  occupying  the  posterior  wall  of  the  cervix.  Delivery 
was  eflfected  by  craniotomy.  The  mental  condition  of  the  woman 
grew  steadily  worse.  A  month  after  confinement  Dr.  Holmes 
removed  the  tumor  by  enucleation.  Her  mental  health  then  be- 
gan at  once  to  improve,  and  within  two  months  after  the  opera- 
tion her  bodily  health  was  excellent  and  she  was  perfectly  sane. 
Two  years  from  that  time  she  was  delivered  naturally  of  a  living 
child.  Her  health  remained  good  for  nine  years.  Then  she 
again  became  melancholy  and  gradually  sank  into  her  old  suicidal 
condition.     She  was  again  brought  to   Dr.   Holmes  for  treat- 


12  SURGERY   AMONG   THE   INSANE   IN    CANADA  [Jw'y 

merit.  He  examined  her  and  found  a  fibroid  tumor  as  large  as 
a  small  lemon  about  the  site  of  that  formerly  removed.  Tliis 
tumor  was  enucleated  as  had  been  the  first  years  before.  In 
three  weeks  she  left  the  hospital,  but  her  mental  condition  did  not 
improve  as  hoped  and  a  few  weeks  later  another  examination 
revealed  the  existence  of  a  third  tumor  about  the  size  of  the 
second  occupying  the  posterior  lower  segment  of  the  uterine 
wall  and  encroaching  on  the  cervical  tissue.  The  removal  of  this 
third  tumor  was  followed  by  prompt  improvement  in  her  mental 
condition  and  she  has  since  remained  quite  well.  It  seems  to  me 
impossible  to  doubt  that  in  this  case  the  tumors  were  the  true 
cause  of  the  attacks  of  insanity. 

Another  case  almost  as  pointed  is  that  of  M.  B.,  who  was 
admitted  into  London  Asylum  i6th  November,  1897,  suffering 
from  subacute  mania  of  eighteen  months'  standing.  She  was 
nineteen  years  of  age;  her  insanity  was  more  pronounced  at  each 
menstrual  period.  She  was  examined  in  December;  it  was 
found  that  the  uterus  was  acutely  anteflexed;  there  was  endo- 
metritis and  both  ovaries  were  enlarged.  The  cervical  canal  was 
almost  occh  led  by  the  antefiexion.  wShe  was  operated  on  at 
once.  The  uterus  was  curetted  and  the  canal  straightened  by 
Dudley's  operation.  Relief  was  tluis  given  to  the  irritated  endo- 
metrium. She  became  sane  ii  mediately  after  the  operation; 
was,  in  fact,  quite  well  the  very  lext  day.  She  remained  well 
two  months,  then  in  February  si  gradually  passed  into  her 
former  insane  condition  and  remained  so  steadily  until  early  in 
April.  She  was  then  re-examined  and  it  was  found  that,  although 
the  first  operation  was  successful  as  far  as  straightening  the  canal 
and  relieving  the  endometritis  went,  yet  the  ovaries  remained 
enlarged.  At  the  time  of  the  first  operation  we,  not  realizing  the 
true  nature  of  the  ovarian  enlargement,  hoped  that  the  uterine 
irritation  being  removed  it  would  subside.  As  it  had  not  done 
so,  we  now  (early  in  April)  removed  the  enlarged  ovaries  per 
vaginam.  They  were  found  to  be  both  cystic  and  almost  void 
of  ovarian  tissue  proper.  After  this  operation  M.  B.  made  a 
good  physical  recovery  and  in  the  course  of  a  week  began  to 
improve  mentally.  During  the  second  week  after  the  operation 
she  recovered  mentally  and  has  been  quite  well  since  and  is 
to-day. 


1898]  R-    M.    BUCKE  13 

I  will  give  briefly  eight  more  of  my  own  cases  to  illustrate  this 
point-  the  point,  namely,  that  the  removal  of  the  physical  dis- 
ease sometimes,  at  all  events,  is  the  actual  efificient  cause  of  the 
mental  recovery  which  follows  thereafter. 

S.  Q. — A  case  of  chronic  mania  with  erotic  delusions  of  three 
and  a  half  years'  standing  at  date  of  operation.  The  case  seemed 
hopeless.  Two  cystic  ovaries  were  removed;  improvement  set 
in  almost  at  once.  In  a  year  after  the  operation  the  patient  v.-as 
much  better  and  she  steadily  improved  until  in  1895,  two  years 
after  the  operation,  she  was  well  and  has  been  so  ever  since. 

A.  S. — A  case  of  chronic  mania  of  two  years'  standing  at  the 
time  of  the  operation.  There  was  apparently  no  prospect  of 
recovery.  In  April,  1895,  a  lacerated  cervix  was  repaired  and 
curettage  performed.  She  began  to  improve  at  once.  By  the 
end  of  1895  she  was  well  and  has  remained  so  ever  since. 

iVI.  M. — A  case  of  chronic  mania  of  over  seven  years'  standing 
at  the  time  of  the  operation.  A  cystic  ovary  was  removed,  a 
lacerated  cervix  repaired,  and  the  uterus  curetted,  in  October, 
1896.  Improvement  set  in  at  once;  by  the  end  of  the  year  she 
was  well  enough  to  go  home  and  has  lived  at  home  since.  Her 
husband  says  she  is  well. 

C.  S. — Became  gradually  insane  from  puberty,  being  always 
much  upset  mentally  at  each  menstrual  period.  She  became 
steadily  worse  as  she  grew  older.  At  the  age  of  tw'enty-six  she 
had  been  a  declared  lunatic  (a  case  of  destructive  mania)  for  five 
years  and  had  been  in  in  asylum  for  the  last  four  of  those  years. 
The  case  was  absolutely  hopeless  and  was  pronounced  so  by  the 
superintendent  of  the  asylum  from  which  she  was  removed  to 
London.  She  was  taken  to  London  Asylum  for  special  examina- 
tion and  (if  thought  well)  treatment.  Examination  revealed  that 
one  ovary  was  converted  into  a  multilocular  cyst  as  large  as  an 
orange,  the  other  was  adherent  to  the  intestine  and  either  atro- 
phied or  had  never  developed.  Both  ovaries  were  removed. 
For  two  months  after  the  operation,  w^hich  was  performed  in 
December,  1896,  she  remained  unchanged  mentally.  Then,  after 
a  final  outburst  of  violence  in  February,  1897,  she  became  almost 
instantaneously  perfectly  sane  and  has  remained  so  ever  since. 
A  marked  feature  of  this  case  is  that  ever  since  her  mental  recov- 
ery, now  fifteen  months  ago,  she  has  menstruated  regularly  and 
without  either  mental  or  bodily  discomfort. 


14  SURGERY   AMONG   THE   INSANE   IN    CANADA  [J"ly 

A.  F. — Picked  up  insane  in  streets  of  London  and  could  give 
no  account  of  herself.  We  found  out  later  that  she  had  been  in  an 
asylum  in  BufTalo.  She  had  been  about  three  years  insane. 
When  she  came  to  us  it  was  a  case  of  incomplete  psychocoma. 
She  would  answer  questions  but  had  no  idea  what  she  said.  She 
would  answer  the  same  question  differenily  a  dozen  times  in  a 
dozen  minutes.  We  examined  her  dniost  at  once  for  pelvic  dis- 
ease. We  found  the  uterus  retrovertod  and  the  ovaries  cystic. 
Uterus  and  ovaries  were  bound  down  in  a  mass  on  the  floor  of 
the  pelvis.  Ovariotomy  and  ventral  fixation  of  the  uterus  were 
performed.  On  the  third  day  after  the  operation  the  woman 
became  suddenly  sane.  She  was  kept  at  the  asylum  (as  she  had 
no  friends  in  Canada)  for  six  months  after  the  operation,  dur- 
ing that  time  she  remained  well.  She  was  discharged  well  and 
sent  to  a  sister  in  Pennsylvania  in  June,  1897.  I  have  not  heard 
from  her  since.     I  suopose  she  keeps  well. 

L.  S. — A  case  of  chronic  mania  of  sixteen  years'  standing.  For 
last  eight  months  worse;  admitted  to  asylum  in  December,  1897; 
examined  on  admission.  The  ovaries  were  enlarged  and  cystic. 
Ovaries,  tubes  and  uterus  were  adherent  one  to  the  other  and 
massed  in  the  cul-de-sac.  nth  January  abdominal  section  and 
removal  of  uterus,  tubes  an^^  ovaries.  Within  a  few  days  after 
the  operation,  as  soon  as  she  was  sufficiently  recovered  to  con- 
verse, she  appeared  to  be  perfectly  well  mentally  and  she  has 
continued  quite  well  to  the  presen^. 

E.  W.  I. — A  case  of  delusional  mania  of  five  years'  standing. 
There  had  been  no  improvement  and  the  case  was  apparently 
hopeless.  She  developed  a  papillomatous  cyst  of  the  right  ovary 
which,  upon  being  removed,  weighed  fifteen  pounds.  The  opera- 
tion was  performed  in  September,  1897.  It  consisted  in  the 
removal  of  both  ovaries  (the  left  was  also  cystic)  and  the  uterus, 
which  was  also  diseased  and  massed  with  the  right  ovary.  She 
improved  almost  at  once  after  the  operation  and  left  the  asylum 
in  December.     She  has  continued  well  ever  since. 

E.  E. — A  case  of  delusional  mania  of  over  two  years'  standing. 
No  apparent  hope  of  recovery.  She  had  subinvolution  of  uterus 
and  a  lacerated  cervix.  In  July,  1895,  curettage  and  trachel- 
orrhaphy were  performed.  She  began  to  improve  both  men- 
tally and  physically  almost  immediately  after  the  operation.     She 


1898]  R.    M.    BUCKE  15 

was  discharged  recovered,  after  three  months'  probation,  in 
March,  1896.  She  has  not  since  been  heard  from  and  I  suppose 
she  keeps  well. 

The  last  eight  of  these  cases  are  selected  as  being,  before  the 
operation  and  without  it,  apparently  hopeless  and  yet  as  all  mak- 
ing good  recoveries.  We  have  many  recoveries,  among  the 
thirty-seven  who  got  we'l,  as  striking  as  these;  but  perhaps  not 
many  which  on  a  cursory  view  would  seem,  before  tl  e  operation, 
so  absolutely  hopeless. 

Th  '  ten  cases  given  seem  to  me  to  afiford  conclusive  evidence 
that  ii  some  cases,  at  least,  the  insanity  rests  upon  the  utero- 
ovarian  disease  and  may  be  cured  by  the  removal  of  this. 

In  estimatui^^  +he  proportion  of  recoveries  and  improvements 
in  the  total  number,  it  must  not  be  forgotten  that  there  are  prob- 
ably quite  a  few  among  those  cases  which  have  been  recently 
operated  on  who  are  present  only  improved,  or  not  even  im- 
proved, yet  who  will  improve  or  even  recover  when  they  have 
had  time  enough.  For  though  many  cases  begin  to  improve 
within  a  few  days  of  the  operation  and  are  soon  almost  or  quite 
well,  there  are  many  others  which  show  little  or  no  change  for 
weeks  or  months  after  the  operation,  yet  who  after  a  time  either 
improve  or  make  perfect  recoveries. 

Now  as  to  the  thirty-two  non-gynecological  cases:  Twenty- 
one  of  these  were  Bassini's  operation  for  the  radical  cure  of 
hernia;  two  were  operations  for  the  removal  of  cancer;  one  was 
for  appendicitis;  one  trephining;  and  seven  were  minor  opera- 
tions. The  result  in  this  group  of  cases  was  markedly  different 
from  the  result  in  the  first  group.  The  physical  health  of  the 
patients  was  in  every  case  improved.  There  was  no  death.  The 
patient  was  made  more  comfortable  and,  as  a  result  of  that, 
apparently,  he  often  became  markedly  less  irritable,  more  amen- 
able to  management,  often  very  much  more  useful  about  the 
asylum;  but  in  no  single  instance  was  there  such  a  change  in 
the  patient  as  could  by  the  most  sanguine  be  called  mental  recov- 
ery or  even  marked  mental  improvement. 

It  seems  plain,  then,  that  it  is  not  simply  the  operation  that 
cures  the  insanity  in  any  case,  but  it  is  something  in  the  kind  of 
operation  performed,  or  rather  in  the  kind  of  disease  which  is 
removed,  which  decides  whether  or  not  the  surgical  procedun-^ 


l6  SURGERY   AMONG   THE   INSANE   IN    CANADA  [July 

is  going  to  efifect  a  radical  change  in  the  patient's  mental  condition. 
Let  us  look  into  this  a  little  closer.  We  have  seen  that  in  thirty- 
two  cases  of  ordinary  surgery  no  cure  or  marked  improvement 
was  effec'Lcd  in  the  mental  state  of  any  of  the  patients;  but  that 
in  one  hundred  and  nine  cases  of  gynecological  surgery  there 
was  either  cure  o'-  marked  improvr-ment  of  the  insanity  seventy- 
one  times.  But  these  gynocolcgical  operations  were  •^'cry  vari- 
ous. For  the  sake  of  illustrating  tht  point  I  am  now  discussing 
I  shall  divide  the  one  hundred  and  nine  cases  into  six  groups  as 
follows: 

1.  Hysterectomies,  i6. 

2.  Removal  of  diseased  ovaries  and  tubes,  12. 

3.  Operations  for  replacing  and  retaining  uterus  in  normal 
position,  22. 

4.  Operations  on  the  cervix,  30. 

5.  Operations  for  minor  uterine  diseases,  21. 

6.  Operations  for  vaginal  lesions,  etc.,  8.  *■ 
Total,  109. 

The  relative  efifect  of  these  dififerent  classes  of  op^  ations  seems 
to  me  most  interesting  and  instructive  and  I  will  ask  you  to 
consider  it  attentively. 

1.  Of  the  sixteen  hysterectomies,  four  recovered  and  three 
improved,  about  44  p.  c. 

2.  Of  the  twelve  ovariotomies,  seven  recovered  and  four  im- 
proved, or  leaving  out  the  patient  who  died,  100  p.  c. 

3.  Out  of  twenty-two  cases  of  replacement  of  the  uterus  there 
were  four  recoveries  and  eleven  improvements,  68  p.  c. 

4.  Out  of  thirty  operations  on  the  cervix  (mostly  amputations) 
there  were  twelve  recoveries  and  nine  improvements,  70  p.  c. 

5.  Out  of  twenty-one  operations  for  minor  uterine  diseases 
(mostly  curettage  and  divulsion)  there  were  twelve  recoveries  and 
two  improvements,  66  p.  c. 

6.  While  out  of  eight  operations  for  vaginal  lesions,  etc.,  there 
were  no  recoveries  and  only  three  improvements,  37  p.  c. 

A  consideration  of  this  analysis  will  show  that  in  our  experi- 
ence neither  the  removal  of  a  diseased  uterus,  nor  the  fixation 
of  a  displaced  uterus,  nor  the  cure  of  a  vaginal  lesion,  has  much 
efifect  in  the  relief  of  insanity;  but  that  when  this  last  results  from 
an  operation  it  is  nearly  always  if  not  always  due  to  either  the 


r  mrra 


1898]  R.    M.    BUCKE  17 

removal  of  diseased  ovaries,  the  amputation  of  a  diseased  cervix 
or  to  the  cure  of  ome  diseased  condition  of  the  endometrium. 
For  it  is  after  these  last  that  recovery  or  improvement  is  oftenost 
observed  and  when  recovery  or  ir  irovcment  follows  other  oper- 
ations it  is  when  some  of  these  last  have  been  done  at  the  same 
time. 

Diseases  of  the  '  varies,  of  the  cervix  and  of  the  mucous  lining 
of  tie  Mterus  then  seem  to  have  more  effect  in  inducing  insanity 
than  have  uterine  tumors  and  uterine  displacements,  tliough 
these  may  cause  more  distress  than  the  former,  and  the  small 
percentage  of  recoveries  in  our  sixteen  cases  of  hysterectomy 
seems  to  me  an  answer  to  the  contention  that  it  is  the  shock  of 
the  operation  and  the  careful  after-attention  to  which  very  largely 
are  due  the  good  effects  of  these  operations.  For  in  our  gyne- 
cological work,  I  need  hardly  say,  the  shock  of  the  operation  is 
greater  and  the  after-attendance  more  strict  and  prolonged  in 
hysterectomies  than  in  and  after  any  other  of  our  operations. 

It  seems,  then,  from  what  little  experience  we  have  had,  that 
an  ordinary  operation,  such  as  a  Bassini  for  hernia,  or  an  opera- 
tion upon  the  vagina,  has  no  curative  effect  upon  a  co-existing 
insanity;  that  the  removal  of  diseased  ovaries  has  an  enormous 
effect,  and  that  curettage,  where  there  is  endometritis,  and  ampu- 
tation of  a  diseased  cervix,  had  an  effect  about  intermediate  be- 
tween these  extremes.  I  am  at  present  inclined  to  believe  that 
the  curative  effect  in  all  our  operative  work  is  due  to  one  or  other 
of  three  things:  Either  to  the  removal  of  diseased  ovaries,  to  the 
cure  of  disease  or  injury  of  the  cervix,  or  to  the  restoration  to  a 
healthy  condition  of  the  inflamed  or  otherwise  diseased  endo- 
metrium. For  where  (with  us)  recovery  has  taken  place  after 
hysterectomy,  diseased  ovaries  have  often  been  removed  at  the 
same  time.  So  the  few  recoveries  that  have  taken  place  after 
replacing  the  uterus  in  position  might  very  likely  have  been  due 
to  the  cuiettage  and  divulsion  simultaneously  practiced.  In  fact, 
it  would  be  almost  absolute  truth  to  say  that  we  have  had  no 
recoveries  apparently  due  to  operations  in  cases  in  which  the 
removal  of  a  diseased  ovary,  operation  upon  the  cervix  or  curet- 
tage have  not,  one  or  other  of  them,  been  practiced. 

Now  you  will  not  fail  to  notice  that  these  three,  the  ovar} ,  the 
endometrium  and  the  cervix  are  the  most  vital,  are  indeed  the 
2 


l8  SURGERY   AMONG   THE    INSANE    IN    CANADA  [July 

creative  organs  of  the  female  sexual  system.  In  them,  in  fact, 
centres  the  life  of  the  woman  as  such,  and  serious  disease  or  even 
functional  disturbance  of  them  does,  we  know,  in  cases  in  which 
there  is  no  question  of  insanity,  always  produce  a  profound  effect 
upon  the  woman's  mental  state. 

But  is  it  not  possible  to  go  a  little  deeper  than  this  general 
statement  and  give  a  more  specific  reason  for  the  probable  bene- 
ficial effects  of  the  removal  of  diseased  ovaries  at  least?  I  think 
it  is.  It  seems  to  me  that  the  recent  physiological  theory  of  so- 
called  internal  secretion  will  furnish  the  clue  that  we  want. 
According  to  this  theory,  there  is  a  "  normal  and  constant  con- 
tribution of  specific  material  by  the  reproductive  glands  to  the 
blood  or  lymph  and  thus  to  the  whole  body."'  This  con  ribu- 
tion  may  be  supplied  or  increased  artificially,  as  by  the  oaily 
injection  of  testicular  juice,  with  very  marked  effect.  But  in 
case  of  disease  of  the  organ  that  supplies  it,  it  is  not  only  liable 
to  be  cut  off  as,  of  course  it  must  be  upon  removal  of  that 
organ,  but  (what  is  perhaps  far  more  serious)  tlie  physiological 
is  liable  to  be  changed  to  a  pathological  contribution  and  the 
internal  secretion  which  was  a  source  of  health  and  energy  to 
the  whole  economy  to  become  a  toxic  agent  of  unknown  but 
probably  great  virulence.  The  removal  of  the  diseased  ovaries 
would  of  course  cut  short  this  poisoning  process  and  enable  the 
vis  medicatrix  to  re-establish  the  health  of  the  individual. 

Thus  much  at  least  may  with  reasonable  probability  be  said  as 
to  the  good  effects  seen  to  follow  the  removal  of  diseased  ovaries. 
Something  of  the  same  kind  may  be  and  I  dare  say  is  true  of  the 
endometrium  and  the  cervix;  but  I  will  not  tax  your  patience  by 
prolonging  the  argument. 

In  conclusion,  I  want  to  point  out  what  I  think  will  be  the 
most  important  outcome  of  the  operative  work  of  which  I  have 
been  speaking.  Should  it  once  be  conceded  by  those  who  have 
charge  of  the  insane,  by  those  men  to  whom  the  general  pro- 
fession looks  for  guidance  in  these  matters,  that  utero-ovarian 
diseases  are  capable  of  acting  as  a  cause  of  insanity  and  that 
removal  of  these  will  in  some  cases  result  in  the  disappearance 
of  the  mental  disturbance,  almost  at  once  it  would  happen  that 

'  American  Text  Book  of  Physiology,  1896,  p.  901. 


1898]  R.    M.    BUCKn  19 

many  insane  women  instead  of  being  sent  to  an  asylum  would  be 
operated  upon  and  relieved  at  home.  More  than  that,  if  the  con- 
nection in  question  were  admitted,  these  women  would  not  be  al- 
lowed to  remain  insane  at  home  for  months  and  often  years  as 
happens  now,  but  would  be  examined,  operated  upon  and  relieved 
within  a  few  weeks  of  the  appearance  of  the  insanity.  More  even 
than  that,  when  the  eyes  of  the  general  profession  are  fully  opened 
upon  this  subject,  symptoms  of  subinvolution,  endometritis,  or 
laceration  of  cervix,  will  be  watched  for  after  child-birth,  and  if 
present,  will  be  at  once  relieved  and  the  woman  who  might  have 
become  insane  in  consequence  of  one  or  other  of  these  lesions 
will  remain  sane. 


